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Hospitals  ana  Medical  Education 


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Columbia  (Hntoertftp 

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College  of  ^Pfjpstctans  anb  burgeons 
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HOSPITALS  AND  MEDICAL 
EDUCATION 


SAMUEL  W.   LAMBERT,  M.  D. 

Dean  of  the  Medical  Faculty 


November  25,  1908 


7 


6-6// 
.£?■ 


To  Dr.  James  W.  McLane,  Messrs.  W.  Irving  Clark  and 
W.  Emlen  Roosevelt,  Committee  in  Behalf  of  the 
Roosevelt  Hospital,  and 

Messrs.  Seth  Low,  W.  Bayard  Cutting  and  Dr.  T.  M. 
Cheesman,  Committee  in  Behalf  of  Columbia  University. 

Gentlemen — 

Your  appointment  as  Committees  of  your  respective  Boards 
was  authorized  by  the  following  resolutions  : 

Resolutions  of  the  Board  of  Trustees  of  Roosevelt  Hos- 
pital, passed  January  28th,  1908  : 

Resolved,  That  a  Committee  of  three,  of  which  the  President 
of  the  Hospital  shall  be  one,  be  appointed  by  the  Presi- 
dent to  consider,  in  conjunction  with  any  committee 
that  may  be  appointed  for  a  similar  purpose  by  the  Trus- 
tees of  Columbia  College  (University),  the  general  sub- 
ject of  methods  of  clinical  instruction  in  the  Hospital. 

Resolved,  That  the  same  Committee  of  this  Board  be  further 
requested  to  consider  plans  for  the  development  and 
extension  both  of  the  existing  buildings  and  the  con- 
struction of  new  buildings  on  the  vacant  land  owned  by 
the  Hospital  on  the  west  of  the  present  buildings. 

Resolution  of  the  Board  of  Trustees  of  Columbia  Univer- 
sity, passed  on  February  3d,  1908  : 

Resolved,  That  a  select  Committee  of  Three  be  appointed 
by  the  Chairman  to  confer  with  the  Committee  appointed 
by  the  Trustees  of  Roosevelt  Hospital  in  reference  to 
extending  the  clinical  facilities  of  the  Hospital  in  con- 
nection with  the  College  of  Physicians  and  Surgeons. 

On  April  10th,  1908,  I  sent  you  a  statement  of  the  reasons 
for  my  asking  that  committees  be  appointed  by  your  respec- 
tive Boards  to  confer  on  the  question  of  the  nearer  relation  of 
the  Roosevelt  Hospital  and  the  College  of  Physicians  and  Sur- 
geons. I  presented  then  as  I  understood  them  the  advantages 
of  increasing  the  teaching  in  the  Hospital  both  to  the  Hospital 
and  the  College. 


The  subject  has  been  thoroughly  canvassed  during  the  past 
summer  and  I  should  like  to  present  my  present  views  on  the 
whole  subject  again.  In  the  Spring  I  suggested  that  $1,000, 
ooo  would  do  much  to  accomplish  the  result  desired,  but  my 
investigations  having  forced  me  to  conclude  that  the  question 
is  a  much  larger  and  broader  one  and  the  scheme  has  developed 
into  one  for  enlarging  Roosevelt  Hospital,  for  increasing  its 
teaching  and  research  functions  and  for  making  it  second  to 
none  in  these  particulars.  As  a  result  of  this  study  the  sum  of 
money  required  for  the  immediate  needs  of  the  hospital  has  in- 
creased to  over  $6,000,000  and  the  completed  plan  calls  for  a 
final  expenditure  of  over  $16,600,000.  The  result  however, 
will,  I  am  sure,  appeal  to  your  Committees  as  an  ideal  to  be 
hoped  for  and  to  be  worked  for.  In  the  desire  to  assist  you  to 
present  this  matter  to  any  prospective  benefactors  of  the  Hos- 
pital in  the  form  of  a  thorough  and  feasible  plan  which  will 
look  to  a  gradual  but  continuous  and  practical  development  of 
the  Hospital,  I  beg  to  submit  the  following: 

During  the  past  five  years  there  has  been  created  in  New 
York  a  great  interest  in  the  hospital  question  in  the  City. 
Several  Committees  have  been  at  work  studying  the  various 
features  of  the  problems  of  present  needs  and  future  develop- 
ment. Two  reports,  destined  to  be  of  far  reaching  influence, 
have  been  published  within  the  past  six  months.  Both  reports 
take  a  broad  view  of  the  whole  situation  and  present  conclu- 
sions based  upon  scientific  study  and  business  principles.  One 
of  these  was  issued  by  the  Commission  on  Public  Hospitals 
appointed  by  his  Honor  Mayor  McClellan,  to  consider  the  or- 
ganization of  the  Municipal  Hospitals.  This  report  deals 
largely  with  the  situation  in  Brooklyn,  Richmond  County  and 
with  the  hospitals  on  Blackwell's  Island.  So  far  as  new  hospi- 
tals in  Manhattan  are  concerned  its  conclusions  do  not  ma- 
terially differ  from  those  of  the  second  report,  which  are 
detailed  below.  Of  the  hospital  needs  of  the  west  side  of 
Manhattan  the  report  says:  "in  the  relatively  near  future  a 
new  general  hospital  with  capacity  for  several  hundred  beds 
should  be  constructed  for  the  middle  west  side  of  the  City  in 
the  Borough  of  Manhattan."  The  second  report  develops  the 
question  more  elaborately  and  forms  report  No.  101  of  the 
State  Charities  Aid  Association  and  presents  an  investigation 


concerning  the  need  both  present  and  future  for  new  hospital 
facilities  in  the  City.  This  report  outlines  a  general  scheme 
for  hospital  extension  which  it  is  hoped  will  be  capable  of  in- 
definite expansion  and  application  to  any  possible  demands 
which  may  arise  in  the  future.  This  co-ordinated  scheme  of 
hospital  relief  demands  three  kinds  of  hospitals  for  acute  dis- 
eases classified  according  to  size  into 

i.    General  hospitals,  or  hospitals  of  1,000  to  1,500  beds. 

2.  Local  hospitals,  or  hospitals  of  100  to  200  beds. 

3.  Emergency  relief  stations,  or  small  ambulance  and  dis- 
pensary hospitals  of  6  to  8  beds. 

The  scheme  further  adds  hospitals  for  convalescents,  hos- 
pitals for  incurables,  hospitals  for  special  diseases,  such  as 
maternity  hospitals  and  those  for  contagious  diseases  (including 
tuberculosis),  and  there  is  suggested  a  plan  for  cooperative 
home  care  of  patients  suffering  from  lesser  ailments  and  of 
those  convalescing  from  acute  diseases. 

If  this  proposed  scheme  of  hospital  development  be  applied 
to  the  present  situation  in  New  York,  and  particularly  to  the 
present  position  of  Roosevelt  Hospital  as  a  part  of  the  general 
hospital  situation,  some  very  interesting  facts  are  manifest. 
The  report  suggests  that  only  two  general  hospitals  (1,500 
beds)  will  be  needed  by  the  year  1920.  One  of  these  is  to  be 
the  new  Bellevue  and  the  other  a  "pavilion"  hospital*  to  be 
built  on  Blackwell's  Island.  The  only  other  hospital  of  any 
size  suggested  for  Manhattan  is  a  local  hospital  of  100  beds  to 
be  developed  (by  1915)  from  an  emergency  relief  station  (to 
be  built  at  once)  in  the  vicinity  of  40th  or  45th  Street  and  9th 
or  10th  Avenue.  This  latter  suggestion  is  to  meet  the  urgent 
deficiency  in  hospital  bed  facility,  both  present  and  prospec- 
tive, which  exists  in  the  middle  west  section  of  the  city  as 
represented  by  the  present  ambulance  district  of  Roosevelt 
Hospital. 

The  chart  showing  the  present  bed  capacity,  the  present 
proper  bed  capacity  and  the  beds  needed  in  1920,  prepared 
by  Mr.  Philip  P.  Jacobs  and  printed  on  pages  40  and  41  of  this 


*  In  this  paper  the  plan  of  hospital  construction  of  a  number  of  isolated  one  or  two-story 
buildings  is  called  a  "  pavilion  "  hospital,  and  the  plan  of  a  compact  building  containing  four 
or  more  stories  is  called  a  "barrack"  hospital.  Roosevelt  Hospital  presents  both  kinds  of 
construction 


report,  emphasizes  this  striking  want  in  the  Roosevelt  sphere 
of  work.  Accepting  the  premises  and  calculations  of  the 
report  as  a  working  hypothesis,  the  three  ambulance  districts 
in  greatest  need  of  beds  are  in  order  of  that  need  as  follows: 


PRESENT  LACK  OF  BEDS,    I905 


PROBABLE  LACK  OF  BEDS  IN  I92O 


Gouverneur  district 283 

J.  Hood  Wright  district 254 

Roosevelt  district 155 

(Omitting  the  private  beds  of    St. 
Elizabeth) 


J.  Hood  Wright  district 781 

Gouverneur  district 360 

Roosevelt  district 357 

(Known  additions  to  present  facil- 
ities are  included  in  this  estimate) 


The  possible  additions  to  the  J.  Hood  Wright  Hospital  and 
to  St.  Luke's  in  the  same  district  leave  little  doubt  but  that 
the  deficiency  for  that  district  in  hospital  beds  will  be  cared 
for.  There  will  remain  in  1920  the  same  two  bad  spots  of 
lack  of  hospital  beds  which  exist  to-day,  the  lower  East  and 
the  middle  West  sections  of  Manhattan.  This  condition  is 
more  evident  when  one  compares  the  above  figures  with  the 
excess  of  beds  in  the  Bellevue  and  Presbyterian  districts, 
which  at  present  are  959  and  202  respectively,  and  which  will 
become  in  1920  for  Bellevue  1,614,  ar>d  for  Presbyterian  59. 
The  excess  in  these  two  districts  does  much  to  overbalance 
the  lack  in  the  intervening  Flower  district  both  present  and 
prospective. 

This  reports  states  very  fully  and  ably  the  arguments  in 
favor  of  a  hospital  of  1,000  beds  and  upwards  as  against  the 
multiplication  of  200  bed  hospitals,  both  in  regard  to  efficiency 
of  administration  and  to  economy  of  expenditure.  But  the 
action  suggested  in  the  report,  namely,  the  placing  of  a  second 
general  hospital  on  the  East  side,  and  on  the  Island  at  that, 
does  not  seem  to  distribute  the  additional  beds  needed  in  the 
best  manner.  A  fairer  conclusion  to  meet  the  conditions 
would  seem  to  favor  the  development  of  a  general  hospital 
(1,000  bed  hospital)  on  the  middle  West  side,  rather  than  as 
proposed,  a  new  local  hospital  of  100  beds,  which  would  not 
even  meet  the  present  demand  for  lacking  beds.  The  loca- 
tion of  Roosevelt  Hospital  fits  it  for  such  a  development,  and 


a  study  of  the  present  service  supports  the  view  that  there  is 
urgently  needed  a  hospital  of  at  least  its  present  size  at  once, 
and  that  a  hospital  four  times  its  size  will  do  no  more  than 
meet  the  conditions  fifteen,  or  even  ten,  years  from  now. 

The  last  report  of  the  Roosevelt  Hospital  (1907;  shows 
that  428  patients  from  the  ambulance  service  alone  were  re- 
fused admission  after  entering  the  reception  ward,  generally 
because  of  lack  of  room,  and  that  for  the  same  reason  1,914 
patients  in  addition  were  taken  to  other  institutions,  or  to 
their  homes  without  being  brought  in  to  the  hospital  at  all. 
These  two  groups  of  cases  form  more  than  half  of  the  actual 
cases  treated  by  the  ambulance  in  the  year  1907  (2,342  out 
of  4,113  patients  treated).  In  other  words,  an  average  of  over 
six  patients  a  day  applied  last  year  for  emergency  treatment 
by  ambulance  call  at  the  Roosevelt  Hospital  and  were  refused 
more  than  the  temporary  treatment  of  the  accident  ward 
because  of  lack  of  room,  and  were  transferred  elsewhere. 
The  hospital  ambulance  service  averaged  14%  calls  per  day, 
one-fifth  of  which  were  unnecessary,  to  such  an  extent  has 
the  abuse  of  the  hospital  ambulance  system  grown  in  New 
York. 

The  service  of  the  Roosevelt  Hospital  is  made  up  not  only 
of  the  sick  poor  from  its  own  neighborhood,  which  is  a  district 
of  great  medical  need,  but  it  has  a  double  source  of  supply 
from  two  large  dispensaries,  its  own  and  the  Vanderbilt  Clinic 
of  the  College  of  Physicians  and  Surgeons,  both  of  which  re- 
fer all  their  patients  needing  hospital  care  to  the  Roosevelt 
Hospital.  It  also  draws  a  large  clientele  because  of  its  own 
reputation  and  of  that  of  its  attending  staff  from  a  large  area 
outside  of  its  own  district,  including  the  suburbs  of  New  York 
and  many  cities  even  at  some  distance.  The  location  is  most 
accessible.  At  one  of  its  corners  there  is  a  station  of  the  Ele- 
vated Railroad  and  at  the  same  point  the  cars  of  three  surface 
lines  pass,  while  a  station  of  the  subway  is  only  one  block  dis- 
tant, and  it  is  in  the  center  of  a  thickly  populated  tenement 
and  factory  district.  It  would  seem  a  justifiable  inference  to 
claim  for  Roosevelt  Hospital  a  manifest  destiny  and  a  future 
development  which  will  make  it  the  large  general  hospital  for 
the  west  side  of  New  York  in  contraposition  to  the  new  Belle- 
vue  which  will  fill  the  same  position  on  the  east  side.     This 


result  should  follow  whether  or  no  a  large  pavilion  hospital  be 
built  on  Blackwell's  Island  or  elsewhere. 

Except  for  the  necessary  funds,  the  facilities  at  the  com- 
mand of  Roosevelt  Hospital  to  fulfil  the  plan  here  suggested  are 
ample.  The  location  of  the  hospital  is  on  high  ground,  and  on 
solid  rock;  its  base  is  77  feet  above  the  Hudson  River  and  as 
near  that  water  as  would  be  possible  at  any  point  on  the  west 
side  of  the  city  (where  the  location  of  the  Hudson  River  R.  R. 
tracks  make  a  duplication  of  the  Bellevue  site  at  26th  St.  and 
the  East  River  impossible).  At  least  in  the  upper  stories  it  is 
near  enough  to  feel  the  influence  of  the  river  breezes.  The 
hospital  site  is  surrounded  on  the  east,  south  and  southeast  by 
comparatively  low  tenements  so  that  a  free  access  of  sunlight 
and  of  the  prevailing  southerly  winds  is  assured.  On  the  west 
there  is  a  High  School  and  on  the  north  the  block  is  occupied 
by  a  large  church  and  by  the  College  of  Physicians  and  Sur- 
geons and  its  accessory  buildings,  the  Sloane  Maternity  and 
the  Vanderbilt  Clinic.  No  material  change  can  be  expected 
to  occur  therefore,  and  the  environment  is  as  available  for  hos- 
pital uses  as  any  city  site  can  be  which  does  not  abut  on  a 
public  park.  The  building  of  a  "  barrack  "  hospital  in  which 
the  wards  are  located  in  the  upper  stories  will  overcome  the 
most  vital  objections  to  that  plan  of  construction,  and  on  a  site 
such  as  has  been  just  described  it  will  fulfil  the  two  essentials 
of  a  healthy  hospital  by  bringing  the  wards  up  into  the  sun 
and  air.  The  ground  plan  of  the  hospital  is  a  city  block,  200  x 
800  feet,  only  two  thirds  of  which  are  occupied'at  present,  and 
as  will  be  developed  later  occupied,  in  part,  in  an  inadequate 
manner.  A  "barrack"  hospital  of  modern  construction  on  a 
ground  plan  of  this  size  would  easily  support  a  thousand  beds. 

Roosevelt  Hospital  today  has  in  it  all  the  elements  which 
make  up  a  large  general  hospital.  It  is  a  teaching  hos- 
pital. It  is  a  research  hospital.  It  has  wards  devoted  to 
medical  specialties.  But  it  is  perfect  in  no  one  branch;  its 
present  equipment  does  not  permit  of  any  approach  to  even  an 
appearance  of  successful  endeavor  to  fulfil  the  efforts  of  its 
workers.  This  statement  must  not  be  taken  as  an  arraignment 
of  the  hospital  staff,  either  lay  or  professional.  The  best  that 
can  be  done  with  present  facilities  is  undoubtedly  done.  But 
Roosevelt  Hospital  fails  to  teach  as  well  as  it  might  because 


7 

the  organization  for  teaching  is  obsolete  and  inadequate.  It 
fails  to  accomplish  the  research  into  the  newer  fields  of  medi- 
cine and  of  surgery  which  its  service  would  permit  and  should 
demand,  because  it  lacks  the  financial  ability  to  develop  this 
department.  It  fails  to  give  the  best  care,  both  medical  and 
surgical,  to  all  the  patients  who  apply  for  aid,  not  that  it  fails 
to  give  such  care  to  the  fortunate  ones  who  are  admitted  to  its 
service,  but  it  fails  in  the  case  of  those  individuals  who  are 
transferred  to  other  institutions  and  who  average  in  the  ambu- 
lance service  alone  six  in  number  daily.  It  possesses  a  division 
of  gynsecological  surgery  but  it  has  no  department  for  that 
purest  of  all  surgical  science,  the  diseases  of  the  eye.  It  has 
a  special  medical  ward  for  children,  but  none  for  the  equally 
important  and  equally  special  branch  of  medical  work,  that  of 
neurology. 

In  developing  Roosevelt  Hospital  into  a  general  hospital  of 
1,000  beds  all  these  factors  must  be  considered.  The  number 
of  specialties  must  be  increased  to  include  at  least  those  men- 
tioned above  and  perhaps  some  others,  though  a  too  close 
specialization  must  be  avoided.  The  principal  additions  to 
the  bed  capacity  .will  of  course  fall  into  the  two  great  divisions 
of  hospital  work,  the  general  surgical  and  the  internal  medical 
wards,  and  both  of  these  departments  require  at  the  present 
time  great  increases  to  meet  the  demands  of  the  present  ser- 
vice for,  as  already  stated,  many  patients  are  refused  admis- 
sion because  of  lack  of  room  alone.  Cases  from  the  subsidiary 
dispensaries  and  those  bringing  independent  admissions  in 
addition  to  those  of  the  ambulance  service  are  often  denied 
admission,  or  their  reception  postponed,  although  they  may 
present  medical  and  surgical  conditions  requiring  early  opera- 
tion, if  not  immediate  treatment. 

The  development  of  Roosevelt  into  a  general  hospital  of 
1,000  beds  must  be  considered  from  the  very  important  point 
of  view  of  the  buildings  of  the  hospital.  The  present  build- 
ings can  be  divided  into  two  groups  of  radical  difference — 
those  which  are  fireproof  and  those  which  are  not.  The  older 
buildings  are  solidly  constructed,  but  they  are  not  fireproof. 
Some  of  them,  notably  Ward  5  (a  single-storied  pavilion  struc- 
ture), were  built  before  the  days  of  aseptic  surgery,  and  with 
the  distinct  idea  in  mind  that  the  building  was  to  be  tempo- 


8 

rary,  because,  owing  to  the  impossibility  of  keeping  hospitals 
free  of  contagion,  especially  that  of  wounds,  it  was  necessary 
to  destroy  and  rebuild  hospital  pavilions  at  certain  intervals. 
Modern  methods  have  changed  all  that,  and  modern  hospitals 
are  composed  of  fireproof  buildings  constructed  of  brick  and 
iron. 

Roosevelt  owns  two  groups  of  buildings  of  the  modern 
type  today.  The  Syms  operating  theatre  with  the  neighbor- 
ing accident  and  children's  wards  on  9th  Avenue  and  the 
building  in  the  centre  of  the  block,  which  contains  the  dis- 
pensary, the  rooms  for  private  patients  and  the  quarters  for 
the  training  school  for  nurses  are  fireproof,  and  should  be 
considered  as  permanent.  But  the  general  ward  building  and 
the  "Ward  5  "  pavilion  could  be  replaced  to  great  advantage 
by  modern  buildings,  which  would  increase  both  the  hospital's 
capacity  and  its  efficiency. 

The  general  plan  of  the  hospital  has  grown  into  that  of  de- 
tached buildings  running  through  the  block  from  north  to 
south  and  connected  for  purposes  of  communication  and  ad- 
ministration by  a  one-story  corridor  on  the  ground  floor  along 
their  north  or  59th  Street  side.  This  cannot  be  improved 
upon,  for  it  embraces  the  best  arrangement  for  furnishing 
sunlight  and  air  to  wards  whose  long  axis  is  north  and  south. 
If  any  criticism  of  this  plan  may  be  offered,  it  is  that  it  de- 
mands rather  a  large  ward  unit  if  the  available  space  is  to  be 
given  up  to  a  single  ward.  This  is  now  done  in  Ward  5,  and 
has  shown  the  advantage  of  economy  in  general  administra- 
tion, though,  perhaps,  a  lack  of  facility  in  conducting  the 
surgical  service.  The  disadvantage  in  this  respect  can  be 
overcome  by  increasing  the  ward  attendance,  even  if  this  de- 
stroys to  a  certain  extent  the  other  advantage — the  economy 
of  large  wards.  The  "  barrack  "  style  of  building  is  an  essen- 
tial of  hospital  construction  in  New  York  City,  where  the 
the  cost  of  land  is  prohibitive  of  the  one  or  two-story  pavilion 
hospital,  except  where  built  by  the  city  itself,  and  then  only 
upon  peculiar  sites  like  Blackwell's  Island  or  in  suburban  dis- 
tricts. If  the  separated  barracks  be  built  as  is  possible  in  the 
Roosevelt  scheme  of  construction,  and  if  the  wards  be  placed 
in  the  upper  stories  of  those  barracks,  all  the  advantages  of 
the  European  Pavilion  system  will  be  secured,   so  far  as  light, 


air  and  quiet  are  concerned,  and  in  as  perfect  a  manner  as  is 
possible  in  a  thickly  populated  environment. 

The  final  plans  should  present  new  barrack  pavilions  on 
the  site  of  the  "Ward  5  "  building  and  on  that  of  the  present 
medical  and  gynaecological  building  and  two  new  barrack 
pavilions  on  the  unoccupied  land  on  the  corner  of  59th  Street 
and  10th  Avenue.  It  should  provide  for  a  new  heating  and 
lighting  plant  sufficient  for  the  whole  hospital  when  com- 
pleted. It  should  provide  for  facilities  for  teaching  and  for 
research  in  connection  with  the  increased  medical  and  surgical 
services  to  be  created.  In  practical  fulfilmeut  of  this  idea  the 
present  administration  building  could  be  left  as  it  stands  ;  for 
much  has  been  done  to  perfect  it  in  the  last  few  years,  and  if 
all  patients  were  removed  from  it  the  room  secured  would 
probably  suffice  for  the  administration  of  the  enlarged  hospi- 
tal. The  general  ward  building  also  might  be  retained  for  a 
last  substitution,  because  it  also  has  been  improved  with  new 
iron  balconies  and  made  as  modern  as  is  possible.  But  the 
present  Ward  5  should  be  removed  and  the  proposed  new 
buildings  on  the  western  end  of  the  site  should  be  added  as 
soon  as  the  funds  can  be  secured  to  build  and  endow  them. 
In  this  new  scheme  of  buildings  certain  changes  and  rearrange- 
ment of  the  departments  could  be  secured.  The  details  of 
this  are  developed  later  and  need  not  be  presented,  at  this 
place.  One  great  advantage  to  be  gained,  however,  may  be 
mentioned  here,  the  transfer  of  the  dispensary  from  its  pres- 
ent quarters  to  the  ground  floor  of  the  proposed  pavilion  on 
the  site  of  Ward  5,  where  it  could  be  in  close  relation  with 
the  present  accident  ward.  This  could  then  become  the  sin- 
gle reception  and  admitting  office  for  the  whole  hospital. 

Roosevelt  Hospital  has  always  been  a  great  teaching  hos- 
pital and  in  its  early  years  it  presented  medicine  and  surgery 
to  its  student  visitors  in  the  best  methods  then  known  and 
practiced.  The  clinics  of  Sands  in  surgery  and  of  Delafield 
and  Draper  in  medicine  were  the  most  sought  after  of  any  in 
the  city.  But  methods  have  changed  and  the  teaching  of  to- 
day requires  a  more  intimate  relationship  and  contact  on  the 
part  of  the  student,  both  with  his  instructor  and  with  the 
patient.  I  have  already  presented  to  you  the  manner  in  which 
this  is  accomplished  by  establishing  in  the  hospital  service  the 


grade  of  clinical  clerk,  and  I  have  shown  the  reasons  why  this 
new  system  acts  alike  for  the  good  of  the  student  and  for 
the  benefit  of  the  patient.  In  reality  I  do  not  overstep  the 
bounds  of  fact  when  I  claim,  that  by  no  other  system  of  hos- 
pital organization  can  the  welfare  of  the  patient  be  served 
equally  successfully. 

One  point  remains  to  be  developed,  the  fact  that  the  adop- 
tion of  these  educational  methods  will  require  the  introduction 
of  certain  details  in  the  construction  of  the  new  buildings. 
The  addition  of  clinical  clerks  will  involve  a  permanent  in- 
crease in  the  working  staff,  demanding  increased  laboratory 
facilities  and  the  addition  of  a  staff  record  room  to  each  ward- 
unit  where  clerical  work  can  be  done.  To  each  division  of  the 
service  there  should  also  be  added  a  study  and  work-room  for 
the  chief  attending  medical  or  surgical  officer  and  his  assist- 
ants. 

The  question  of  applying  methods  of  scientific  research  to 
the  patients  of  a  hospital  is  no  longer  subject  to  questioning 
criticism.     Such  methods  do  not  involve  the  old  bugbear  of 
experimenting  on  hospital  patients,  implying  as  it  did,  that 
such  experiments  were  a  detriment  and  menace  to  the  sick  and 
suffering.     On    the    contrary,   medical    research   has    led    not 
only  to  the  better  care  of  future   patients,  but  also   to   the 
better  understanding  and  treatment  of  the  individual  who  is 
"experimented"  upon.     All  forms   of    medical   research  are 
closely  linked  with  medical  teaching    and  require    the  large 
plants  for  scientific  study  which  are  to  be  found  only  in  speci- 
fically endowed  institutes  like  the  Rockefeller  Institute  in  New 
York  and  the  Ayer  Institute  in  Philadelphia,  or  at  Columbia  and 
other  large  universities.     Medical  research  requires  also  many 
helpers  in  higher  and  lower  positions,  and  no  better  assistance 
can  be  secured  in  the  lower  grades  than  a  sufficient  number  of 
undergraduate  students  enthusiastic  in  their  work,   eager  to 
learn,  and  under  the  disciplinary  control  of  their  instructors. 
The  Roosevelt  Hospital  is  fortunate  in  being  situated  opposite 
the  College   of    Physicians  and  Surgeons,   with    its    scientific 
establishments  of  pathology,  bacteriology,  clinical  pathology, 
pharmacology  and  chemistry.     The  hospital  has  depended  in 
the  past  for  its  higher  investigations  in  pathology  and  bacter- 
iology entirely  upon  the  college  laboratories.     In  the  proposed 


plan  of  creating  closer  relations  between  the  two  institutions 
this  connection  should  be  strengthened  and  extended  to  in- 
clude the  other  departments  mentioned  above.  The  new 
laboratories  to  be  created  on  the  hospital  grounds  should  be 
under  the  same  control  and  supervision  as  the  college  labora- 
tories. In  other  words,  in  all  departments  the  same  man 
should  be  responsible  for  the  work  both  in  the  College  and 
the  Hospital.  The  pathologist  of  the  Hospital,  for  example, 
should  be  Professor  of  Pathology  in  the  College,  just  as  the 
surgeons  of  the  hospital  are  the  professors  of  surgery  in  the 
neighbouring  institution.  That  the  scientific  value  of  such 
departments  as  chemistry  and  pathology  would  be  greatest  in 
the  College  would  be  counterbalanced  by  the  fact  that  the 
greatest  reputation  and  importance  would  rest  in  the  hospital, 
in  the  practical  clinical  branches  such  as  surgery  and  medicine. 
In  this  way  a  balance  would  be  struck  and  both  institutions 
would  increase  the  scientific  renown  of  its  ally  in  the  study, 
teaching  and  investigation  of  medical  art  and  science. 

At  present,  there  is  in  the  Roosevelt  Hospital  a  marked  lack 
of  uniformity  in  the  scheme  of  organization  of  its  medical  and 
surgical  staffs.  No  one  of  the  four  branches  of  medical  practice 
which  are  represented  in  the  hospital  service  at  present  has  an 
organization  similar  to  that  of  any  other.  Several  possible 
varieties  of  organization  are  represented.  The  medical  service 
has  an  attending  staff  of  three  physicians  who  divide  the  winter 
months  between  them,  and  relegate  the  summer  service  to  a 
junior  attending.  The  authority  of  this  junior,  however,  is  in 
no  way  less  than  that  of  his  senior  colleagues,  except  in  this 
one  particular  of  choice  of  season  for  work.  As  there  are  no 
assistants  on  the  medical  service,  enforced  absences  from  duty 
must  be  delegated  by  request  of  the  physician  on  duty  to  some 
one  of  his  co-equal  colleagues.  The  two  surgical  services  are 
each  organized  with  a  senior  surgeon  serving  eight  months  and 
a  junior  surgeon  serving  four  months,  the  latter  in  the  summer 
only.  There  are  two  assistants  to  each  division.  Absences  by 
leave  (vacation,  etc.)  of  the  surgeons  must  be  filled  by  another 
of  the  staff  of  equal  grade,  assistants  by  an  assistant,  attending 
surgeon  by  an  attending  surgeon,  except  that  some  slight 
latitude  is  allowed  in  that  an  assistant  can  substitute  for  his 
chief  for  single  periods  of  twenty-four  hours.    The  gynsecologi- 


cal  service  has  a  single  attending  and  a  Junior  attending,  who 
can  substitute  for  his  Senior  in  all  things  and  for  all  periods  of 
time,  subject  only  to  the  controlling  wish  of  the  Senior 
himself. 

In  these  three  divisions  a  needed  elasticity  is  secured  by 
extending  the  powers  of  the  heads  of  the  dispensary  service, 
and  the  chiefs  of  clinic  in  medicine  and  gynaecology  may  be 
permitted  to  do  duty  in  the  wards  by  a  vote  of  the  visiting 
committee  of  the  Board  of  Trustees  upon  each  special  case  as 
it  arises.  The  chief  of  clinic  in  surgery  has  recently  been 
advanced  permanently  to  the  position  of  second  assistant  on 
one  of  the  surgical  divisions,  to  meet  the  increasing  demands 
for  work.  The  final  point  to  be  brought  out  is  that  the  division 
for  children's  diseases  has  no  attending  staff  of  its  own,  but 
is  attached  to  the  general  medical  service.  These  details  of 
organization  are  presented  here  because  it  is  believed  that  the 
co-existence  of  all  of  them  in  one  institution  cannot  serve  for 
the  best  interests  of  the  hospital,  and  it  is  believed  that  the 
best  system  is  not  too  good  for  the  Roosevelt  Hospital  and 
should  prevail  in  all  its  divisions. 

The  oldest  American  idea  of  hospital  organization  (both 
medical  and  surgical),  is  the  one  of  multiple  heads  serving  in 
rotation  for  equal  portions  of  the  year.  The  arguments  usually 
offered  in  favor  of  such  a  plan  of  service  are  in  themselves  at 
least  in  part  condemnatory.  The  arguments  are,  that  a  change 
of  physicians  is  beneficial  to  the  individual  patient,  that  com- 
petent physicians  will  not  serve  in  the  subordinate  position 
made  necessary  by  the  plan  of  a  single  head  of  division,  and 
that  the  rivalry  of  succeeding  attending  physicians  is  for  the 
good  of  the  service.  In  recent  years  New  York  has  been 
visited  by  a  number  of  eminent  European  physicians  who  have 
made  a  study  of  our  institutions  and  methods,  and  their  judg- 
ment with  regard  to  these  questions  is  significant.  Prof.  Von 
Noorden,  for  example,  condemns  the  American  rotating  system 
of  hospital  service  as  follows: 

"Excepting  in  the  case  of  a  very  energetic  and  especially 
qualified  personality,  they  (attending  physicians)  possess  no 
satisfactory  control  over  the  service,  the  assistants  and  the 
nurses.  They  are  in  general  more  like  highly  esteemed  guests 
than  masters  in  the  house." 


*3 

The  only  seemingly  favorable  criticism  which  I  have  found 
is  by  Prof.  F.  Miiller,  of  Munich  (who  represents  the  most 
perfect  development  of  the  other  extreme),  in  a  series  of 
"  Impressions  of  an  American  Journey."  Even  he  finds  more 
disadvantages  than  advantages  in  this  " American"  system: 

"This  system  has  the  advantage  that  many  physicians  are 
connected  with  the  hospital,  who  can  use  their  influence  in 
behalf  of  the  hospital  and  secure  for  themselves  an  incentive 
to  and  advancement  of  their  own  knowledge  and  ability. 
But  the  advantages  which  are  secured  to  the  physicians  have 
disadvantages  as  well  added  thereto.  There  is  lacking  a 
uniform  professional  direction  especially  in  a  therapeutic  sense 
which  is  more  important  in  a  surgical  than  in  a  medical  sense. 
No  one  physician  is  responsible  for  the  whole  direction  and 
training  of  the  assistants  and  of  the  nursing  staff,  which  must 
suffer  thereby.  One  gets  the  impression  from  this  American 
system  that  the  head  of  the  nurses  training  school  and  the 
interne  assistant  has  greater  influence  on  the  conduct  of  the 
service  than  the  attending  physician  possesses." 

In  referring  to  the  "one  man  system"  of  Johns  Hopkins, 
Miiller  expresses  the  opinion  "that  this  example  will  find  in 
the  future  a  wide-spread  imitative  extension  which  will  result 
in  a  distinct  advantage  to  the  hospitals." 

The  arguments  in  favor  of  the  system  of  rotation  are 
easily  refuted.  It  is  not  true  that  equally  competent  physi- 
cians will  not  serve  as  assistants  one  to  the  other.  The 
benefit  of  a  change  of  physician  occuring  four  times  a  year  is 
at  best  of  petty  consideration  in  comparison  with  the  daily 
consultation  of  one  physician  and  his  assistant,  both  of  whom 
are  conversant  with  the  progress  of  every  individual  case. 
As  a  matter  of  fact  the  rivalry  of  the  several  members  of  a 
rotating  staff  is  not  keen.  They  probably  are  the  last  persons 
to  be  conscious  of  the  comparisons  passed  upon  them  by  the 
house  staff  or  other  critics. 

The  single  headed  division  would  seem  to  be  the  logical 
method  of  organization.  A  hospital  is  successful  in  proportion 
as  it  approaches  a  military  discipline,  and  a  multiheaded  army 
is  inconceivable.  To  compare  hospital  services  with  the  work 
of  civil  life  it  can  be  asserted  confidently  that  no  successful 
business  is  conducted  on  such  a  plan.  The  single  headed 
division  has  reached  its  greatest  development  in  Europe  and 
especially  in    military   Germany.     It  has  been   implanted   in 


14 

America,  notably  in  Johns  Hopkins  and  in  this  city  in  the 
Sloane  Maternity  and  the  Lying-in  Hospital,  in  Mt.  Sinai  and 
in  the  Hospital  for  Ruptured  and  Crippled.  Roosevelt  has  it 
in  the  Gynaecological  service  and  had  it  formerly  in  the  surgi- 
cal service.  No  one  thing  ever  increased  the  good  name  of 
the  Roosevelt  Hospital  more  than  the  single  headed  surgical 
service  under  Henry  B.  Sands  and  his  remarkably  talented 
assistants  Halstead,  Hall  and  Hartley.  Such  a  service  refutes 
every  argument  against  the  system.  It  is  found  wherever 
medicine  flourishes  best  and  is  an  absolute  essential  for  any 
hospital  which  wishes  to  teach  with  the  best  results  and  to 
further  the  highest  medical  research.  The  only  argument  to 
be  offered  against  it  is  that  the  chief  of  the  service  will  neglect 
it  and  turn  the  work  over  to  his  assistants.  The  remedy  is 
theoretically  simple  and  lies  in  the  hands  of  the  Trustees. 
But  practically  it  is  often  difficult  and  it  is  always  disagreeable 
to  apply  a  drastic  remedy.  Such  neglect,  however,  is  not 
confined  to  hospitals  of  single  headed  divisions;  every  hospi- 
tal has  suffered  from  such  faults  in  individual  members  of 
its  attending  staff.  This  inefficiency  on  the  other  hand  would 
be  controlled  and  corrected  with  greater  ease  in  a  hospital 
which  demands  teaching  from  its  attending  staff.  The  outcry 
of  students  against  neglect  is  more  certain  and  more  loud 
than  that  of  the  patients  of  a  hospital.  In  fact  no  neglect 
to  patients  may  result  from  the  elision  of  the  attending 
physician  for  they  may  be  as  well  or  even  better  cared  for  by 
his  assistant. 

The  enlargement  of  Roosevelt  Hospital,  if  made  possible, 
will  give  an  opportunity  to  create  several  divisions  of  equal 
size,  each  possessing  the  same  functions.  Roosevelt  already 
has  two  surgical  divisions,  and  it  could  with  advantage 
add  other  divisions  to  its  medical  work  as  well.  In  fact 
an  increase  in  work  is  possible  in  no  other  way.  The  crea- 
tion of  parallel  and  equivalent  divisions  will  in  itself  accom- 
plish the  best  method  of  developing  a  friendly  rivalry  and 
kindly  criticism  between  the  several  attending  and  resident 
staffs.  Such  a  rivalry,  which  utterly  fails  as  between  rotat- 
ing services,  would  be  the  keenest  possible  between  co-exist- 
ent services,  all  of  which  have  in  common  the  three-fold 
endeavor  —  of  advancing  human   knowledge   in  medicine,  of 


i5 

teaching  students  and  of  serving  the  ill  and  suffering  patients 
of  the  institution. 

The  medical  organization  of  a  large  general  hospital  of 
1,000  beds  would  demand  a  clinical  staff  and  a  scientific  staff, 
each  of  which  would  be  divided  into  the  two  general  subdivis- 
ions of  attending,  or  non-resident,  and  subordinate,  or  resi- 
dent. It  would  demand  an  unequal  division  into  surgical  beds, 
medical  beds  and  beds  for  specialties.  An  exact  partition  is 
not  possible  on  d  priori  grounds,  but  a  tentative  scheme  for 
eighteen  single-headed  divisions  may  be  assumed  as  follows  : 

400  surgical  beds  in  4  divisions  of  100  beds  each. 
400  medical  beds  in  8  divisions  of  50  beds  each. 

50  beds  for  a  children's  division. 

25  beds  for  a  gynaecological  division. 

50  beds  for  an  ophthalmological  division. 

25  beds  for  a  neurological  division. 

25  beds  for  a  nose,  throat  and  ear  division. 

25  beds  for  a  genito-urinary  division. 

This  variation  in  size  is  warranted  by  the  difference  in  the 
service  demanded.  A  surgical  service  should  be  large  enough 
to  furnish  active  operative  material  and  also  to  supply 
beds  for  those  surgical  cases  which  require  a  long  convales- 
cence and  but  little  active  treatment.  The  large  group  of 
fracture  cases  are  barred  from  most  surgical  wards  to-day 
because  they  crowd  out  acute  operative  work.  It  is  found  in 
practice  that  50  beds  is  about  the  limit  of  acute  medical  cases 
which  one  staff  can  intelligently  handle.  The  other  figures 
are  an  attempt  to  estimate  the  demand  for  cases  in  such 
specialties. 

No  mention  is  made  here  of  private  patients.  It  is  believed 
that  the  only  good  reason  for  a  general  hospital  to  take  care 
of  the  private  patients  of  their  attending  staff  is  that  the 
hospital  can  make  money  out  of  that  end  of  the  business.  It 
is  believed  that  it  rarely  pays  a  hospital  to  undertake  such 
work,  and  it  is  further  believed  that  it  is  wise  for  an  attend- 
ing physician  or  surgeon  to  separate  his  public  and  hospital 
service  from  his  private  practice.  If,  however,  a  general 
hospital    proposes    to    undertake  this  class  of    service,    it   is 


i6 

almost  self-evident  that  the  hospital  should  provide  a  special 
building'  with  operating  rooms  for  the  exclusive  use  of  this 
work,  and  a  separate  resident  staff,  who  should  be  a  paid 
staff.  It  is  true  that  the  double  duty  has  been  tried  by  some 
hospitals,  and  with  success,  and  that  Roosevelt  is  a  notable 
example  of  such  a  hospital,  but  friction  will  result  from  neglect 
of  one  or  the  other  subdivision  sooner  or  later,  and  serious 
complications  can  be  surely  avoided  only  by  a  separation  of 
these  duties. 

Each  of  the  eighteen  divisions  indicated  above  should  form 
a  single  headed  staff.  The  surgical  and  medical  staffs  should 
consist  of  a  chief  attending  or  director;  of  at  least  four  assist- 
ants, one  of  whom  should  work  mainly  in  the  out-patient  de- 
partment as  chief  of  clinic.  There  should  be  a  resident  whose 
duties  are  at  present  new  to  New  York  institutions.  They  are 
described  in  detail  below.  The  resident  interne  staff  on  each 
division  could  be  reduced  to  that  formerly  in  vogue,  namely: 
a  house,  a  senior  and  a  junior  serving  six  months  in  each 
grade,  or  18  months  in  all.  And  finally  there  would  be  a 
group  of  4th  year  medical  students  to  serve  as  clinical  clerks. 
The  number  of  these  should  be  in  the  proportion  of  one  "to 
every  eight  beds. 

The  new  position  of  resident  is  required  by  the  new  posi- 
tions of  clinical  clerks.  He  will  have  immediate  oversight  of 
the  house  staff  in  general  and  of  those  lower  members  of  it  in 
particular.  In  addition  he  will  have  general  control  of  the 
admissions  and  discharges  and  on  the  surgical  side  will  have  a 
general  oversight  of  the  accident  ward.  Such  a  resident  offi- 
cer should  be  appointed  for  each  division.  It  is  believed  that 
these  positions  would  be  eagerly  sought  by  members  graduat- 
ing from  the  house  staff  and  that  many  men  will  hold  this  posi- 
tion, if  it  be  established,  for  periods  of  one,  two  or  more  years. 
This  position  should  differ  from  the  other  positions  of  the  in- 
terne staff  in  that  it  should  be  salaried.  The  services  of  the 
medical  specialties  which  consist  of  a  smaller  number  of  beds 
than  the  general  medical  and  surgical  services  would  require  a 
smaller  house  staff.  Those  services  which  are  operative  in 
nature,  such  as  gynaecology  and  diseases  of  the  eye,  would  re- 
quire a  single  attending  with  only  two  assistants  and  a  house 
staff  of  two  serving  in  two  grades  of  six  months  each.   Clinical 


i7 

clerks  could  be  admitted  to  these  services  in  the  same  man- 
ner as  on  the  general  wards,  but  perhaps  in  a  different  ratio, 
say,  one  to  twelve  instead  of  one  to  eight  beds.  The  non-op- 
erative specialties,  such  as  diseases  of  the  nervous  system, 
would  require  the  two  assistants  for  the  chief  attending  and  a 
house  staff  of  perhaps  a  single  resident,  whose  service  might 
be  indefinite  in  time  and  whose  duties  could  cover  both  those 
of  the  resident  on  the  general  medical  services  and  those  of 
the  regular  house  staff.  Clinical  clerks  would  be  admitted 
also  and  in  the  same  manner  as  in  the  general  wards.  The 
service  for  diseases  of  children,  consisting  of  fifty  beds,  would 
require  a  similar  organization  to  that  already  outlined  for  the 
general  medical  service.  It  is  believed  that  the  position  of 
resident  and  house  staff  in  these  special  services  would  be 
sought  after  by  men  who  had  had  previous  hospital  training, 
either  in  general  medicine  or  general  surgery. 

In  addition  to  the  clinical  staff,  the  organization  of  which 
has  just  been  described,  there  must  be  a  scientific  staff  to 
direct  and  perform  the  work  in  the  sciences  allied  to  medicine 
which  are  necessary  in  modern  practice  both  to  further  and 
complete  the  diagnosis  and  therapeutics  of  the  individual 
case,  and  to  carry  on  the  medical  research  into  the  causation 
and  study  of  disease.  These  scientific  positions  should  in 
some  cases  be  separated  from  the  clinical  staff  and  in  some 
the  same  incumbent  should  hold  both  places.  As  distinguished 
from  the  clinical  division  there  should  be  scientific  depart- 
ments of  Pathology,  of  Clinical  Pathology,  of  Bacteriology 
and  of  Chemistry.  Each  of  these  four  divisions  must  have  a 
laboratory  plant  in  which  to  work  and  a  staff  of  workers,  who 
should  be  constantly  in  touch  with  the  wards  and  the  patients 
of  the  hospital.  The  relation  of  these  scientific  departments 
must  be  intimate  also  with  the  teaching  of  medicine.  Medical 
research  of  the  broadest  kind  can  be  accomplished  only  in 
connection  with  actual  cases  of  disease  on  the  one  hand  and 
with  that  most  eager  seeker  for  knowledge,  the  medical 
student,  on  the  other.  The  relation  of  a  hospital  staff — both 
clinical  and  scientific — to  the  teaching  staff  of  a  school  of 
medicine  should  be  as  intimate  as  possible  if  the  best  renown 
is  to  come  to  both.  Dr.  Goldwater,  the  superintendent  of 
Mt.  Sinai  hospital,  has  recently  written: 


i8 

"I  often  think  that  the  pre-eminence  of  Johns  Hopkins 
among  American  hospitals  has  been  won  with  an  ease  that  is 
not  creditable  to  other  institutions.  In  wet-blanketing  the 
ardor  of  scientific  enthusiasm,  in  shutting  their  doors  in  the 
face  of  the  research  worker  and  its  medical  student,  hospitals 
have  abandoned  their  claims  to  distinction  and  have  stunted 
their  own  growth.  Sentimentality  has  commanded  them  to 
lock  up  their  priceless  storehouses  of  knowledge  and  medical 
science  in  America  has  been  half  starved  in  consequence." 

To  apply  these  cardinal  principles  to  the  case  of  the 
Roosevelt  Hospital  and  the  College  of  Physicians  and  Surgeons 
it  must  be  pointed  out  that  the  heads  of  every  division  of  the 
hospital,  both  clinical  and  scientific,  should  be  teaching  officials 
of  the  College  as  well.  So  far  as  the  clinical  staff  is  concerned 
this  is  now  true  with  some  minor  exceptions.  It  should  be  made 
equally  true  not  only  of  the  scientific  departments  which  already 
exist,  but  also  of  those  which  should  be  created  and  there 
should  be  no  exceptions  whatever,  not  even  minor  ones. 

It  is  true  that  up  to  the  present  time,  the  work  which  has 
been  done  in  bacteriology  and  in  pathology  for  the  hospital 
has  been  done  very  largely  in  the  College  laboratories.  But 
the  connection  has  been  poorly  organized,  the  link  between 
the  two  institutions  has  been  made  through  some  minor  official 
of  the  College  staff.  Thus  while  the  attending  surgeon  of  the 
hospital  has  been  the  Professor  of  Surgery  at  the  College  the 
pathologist  of  the  hospital  has  been  only  an  instructor,  or,  at 
most,  an  adjunct  Professor  of  Pathology  at  the  College.  The 
bacteriology  at  the  hospital  has  been  done  by  a  so-called  first 
assistant  to  the  hospital  pathologist,  who  held  a  subordinate 
position  in  the  College  of  instructor  of  pathology  and  had  no 
connection  with  the  department  of  bacteriology  of  the  College 
at  all.  Of  chemistry  the  hospital  has  no  service  whatever. 
Such  an  arrangement  has  led  inevitably  to  friction  in  adminis- 
tration and  at  times  to  serious  delay  or  even  failure  in  securing 
results.  The  hospital  has  recently  been  presented  with  a  new 
laboratory  building  for  the  housing  of  some  of  the  work  of 
this  kind.  Such  a  building  is  urgently  needed  and  will  supply 
one  of  the  means  of  carrying  out  an  ideal  organization.  But  it 
should  not  remove  from  the  College  the  burden  of  supplying  the 
means  of  carrying  on  the  more  advanced  investigations  of  medi- 
cal research  in  pathology,  in  bacteriology  and  in  chemistry. 


*9 

Each  of  these  departments  in  the  hospital  should  be  organ- 
ized somewhat  as  follows,  taking  the  department  of  pathology 
as  an  example: — Director  of  Pathology  (the  incumbent  to  be 
also  Professor  of  Pathology  in  the  College  of  Physicians  and 
Surgeons).  Assistant-Director  (in  charge  of  the  Hospital 
laboratory)  with  one  worker  to  each  medical  or  surgical 
division,  who  should  hold  a  combined  scientific  and  clinical 
position  and  be  known  as  Pathologist  and  Assistant  Physician, 
or  Surgeon,  as  the  case  might  be.  In  the  same  way  the  Pro- 
fessors of  Bacteriology  and  of  Chemistry  at  the  College  should 
hold  the  positions  of  Consulting  Bacteriologist  or  Chemist  and 
Director  of  laboratory.  By  such  a  scheme  the  duplication 
of  effort  on  both  sides  of  59th  Street  and  the  present 
possibility  of  friction  would  be  avoided.  The  hospital  would 
get  better  service  from  the  College  than  now,  and  the  College 
would  continue  to  do  for  the  hospital,  in  a  more  feasible  man- 
ner, the  work  for  their  mutual  benefit  which  it  is  now  doing, 
and  which  it  is  glad  to  do. 

The  financial  side  of  this  question  presents  several  import- 
ant features.  From  its  fixed  resources  Roosevelt  Hospital  is 
to-day  unable  to  meet  the  demands  of  the  present  service  as  at 
present  administered.  The  hospital  is  working  at  an  annual 
deficit  of  from  $8,000  to  $15,000.  This  has  been  met  of  late 
years  by  donations  from  its  friends,  prominent  among  whom 
are  certain  of  the  Trustees.  In  addition  to  this  deficit  the 
hospital  is  seriously  threatened  with  a  further  deficit  from  the 
collection  of  taxes  upon  its  income-bearing  real  estate.  If  this 
burden  is  to  be  added  to  the  hospital  liabilities,  an  additional 
annual  income  of  at  least  $12,000  must  be  furnished  in  order 
to  bring  the  hospital  upon  an  even  balance.  The  hospital 
needs,  therefore,  in  order  to  meet  its  present  emergencies,  an 
added  annual  income  of  at  least  $25,000,  which  represents  an 
investment  of  $500,000  at  5$. 

This  sum,  however,  is  a  mere  nothing  compared  to  the 
amount  of  money  which  is  needed  to  develop  Roosevelt  Hos- 
pital upon  the  plans  as  above  outlined.  The  following  pages 
will  show  what  is  needed  for  the  construction  of  the  completed 
hospital;  for  the  endowment  of  its  economic  departments  to 
take  care  of  the  daily  needs  of  the  patients  and  the  staff;  for 
the  support  of  the  teaching  and  research  staff  organizations 


which  have  been  described  in  detail  in  the  preceding  pages. 
A  study  of  these  estimates  shows  that  the  ultimate  develop- 
ment of  the  Roosevelt  Hospital  into  a  general  hospital  of  1,000 
beds  with  the  necessary  modern  equipment  for  medical  re- 
search for  teaching  and  for  scientific  care  of  its  patients  will 
require  $16,500,000.  Of  this  large  sum  $500,000  is  needed  to 
meet  the  immediate  needs  of  the  present  plant,  and  $6,000,000 
to  secure  to  the  hospital  the  development  and  enlargement 
which  is  urgently  required  at  the  present  time.  If  this  latter 
sum  can  be  secured  the  hospital  will  take  its  place  at  once 
among  the  great  hospitals  of  the  world,  and  in  the  first  rank 
of  such  hospitals. 

In  regard  to  the  expenditure  of  so  large  a  sum  of  money  as 
the  total  ($16,500,000),  which  is  asked  for  to  convert  Roosevelt 
Hospital  into  the  West  side  general  hospital  of  New  York 
City,  it  is  interesting  to  compare  it  with  the  amount  which  it 
is  proposed  to  expend  upon  Bellevue  Hospital,  the  proposed 
general  hospital  of  the  East  side  of  New  York.  Bellevue 
Hospital  is  being  converted  from  a  1,000  bed  hospital  to  a 
2,000  bed  hospital  upon  the  modern  basis  of  construction, 
which  involves  its  entire  rebuilding  and  the  destruction  of 
all  of  the  old  plant.  This  will  cost  in  the  neighborhood 
of  ten  million  of  dollars,  and  not  a  single  dollar  is  being  pro- 
vided for  endowment.  The  maintenance  of  the  hospital  will 
continue  to  be  met  from  the  annual  taxes  of  the  city.  In  the 
case  proposed  for  Roosevelt  Hospital  a  sum  of  only  half  as 
much  again  will  convert  a  200  bed  hospital  to  one  of  a  1,000 
beds  and  there  will  be  provided,  not  only  the  entire  plant  but 
a  laboratory  system  for  the  furthering  of  medical  knowledge, 
both  in  research  and  in  teaching,  and  in  addition  the  entire 
endowment  necessary  for  adequate  maintenance. 

These  ideas  are  being  presented  to  you  in  the  hope  that 
they  may  interest  prospective  donors  to  contribute  to  the 
development  of  medical  education  in  the  City  of  New  York 
on  a  plane  commensurate  with  the  importance  and  dignity  of 
the  position  of  the  city  in  the  United  States. 

The  financial  questions  involved  in  bringing  about  the 
development  of  Roosevelt  Hospital  as  outlined  above  include 
the  securing  of  funds  for  three  distinct  purposes: 


I.    Building  funds  to  erect  the  new  buildings  of  the 

proposed  enlarged  hospital. 
II.  Endowment  funds  to  provide  the  ordinary  main- 
tenance of  hospital  beds,  including  all  expenses 
except  those  to  be  strictly  considered  as  educa- 
tional and  scientific. 
III.  Endowment  funds  to  provide  for  the  establishing 
of  a  proper  system  of  medical  education  and 
medical  research. 

t.  The  new  buildings  required  by  the  suggested  plans 
would  naturally  consist  of  three  buildings  of  about  the  size 
and  shape  of  the  present  hospital  structure  known  as  the 
"  Pay-patient  Pavilion."  One  of  these  new  buildings  would 
be  placed  on  the  site  of  the  present  "Ward  5  "  and  the  two 
others  on  the  vacant  land  on  the  western  end  of  the  hospital 
property.  These  "barrack"  pavilions  would  be  made  up  in 
large  part  of  ward  units,  though  some  part  of  the  most  west- 
erly one  would  contain  a  new  hospital  stable  and  hospital 
morgue,  and  perhaps  a  medical  teaching  plant  similar  to  the 
Syms  pavilion,  which  is  designated  for  surgical  educational 
purposes.  It  is  believed  that  each  of  these  buildings  would 
cost  about  $250,000,  irrespective  of  the  peculiar  uses  to 
which  it  might  be  put.  The  completed  hospital  would  need 
also  an  enlarged  heating  and  lighting  plant,  with  an  enlarged 
building  therefor.  If  this  is  to  be  placed  in  the  position  of  the 
present  installation  it  might  demand  the  destruction  of  the 
medical  ward  building.  This  is  an  old  non-fireproof  struc- 
ture, which  could  profitably  be  removed  to  give  place  to  a 
new  building  constructed  on  modern  lines.  It  is  probable 
that  this  change  could  be  effected  also  at  an  expense  of 
$250,000.  Until  some  skilled  architect  has  drawn  the  plans 
and  specifications  it  is  impossible,  of  course,  to  state  accu- 
rately the  amount  of  money  needed  for  building  purposes,  but 
it  seems  fair  to  assume  that  $1,000,000  would  suffice  to  con- 
vert the  present  250-bed  Roosevelt  Hospital  into  a  modern 
institution  of  1,000  beds,  so  far  as  the  mere  matter  of  iron, 
bricks  and  mortar  is  concerned. 

2.  The  largest  item  of  every  hospital  foundation  is  the 
funded  endowment  needed  to  meet  the  annual  running  expenses. 


The  Roosevelt  Hospital  has  been  caring  for  its  patients 
for  several  years  past  at  the  rate  of  from  $2. 23  (1906)  to  $2. 28 
(1907)  per  patient  per  day,  after  deducting  the  necessary  ex- 
penses for  running  the  accident  and  dispensary  services.  The 
expenses  of  supporting  a  hospital  are  continually  increasing 
both  from  greater  demands  of  medical  and  surgical  treatment 
and  from  increasing  cost  of  wages  and  supplies.  I  have  for 
the  purposes  of  this  estimate  taken  $2.50  as  the  total  charge 
against  the  single  "patient-day"  item  when  all  expenses  are 
included.  While  this  figure  ($2.50)  is  perhaps  too  low  for  pres- 
ent estimates  on  the  Roosevelt  Hospital  of  today,  the  relative 
expense  of  a  1,000  bed  hospital  would  be  slightly  reduced  be- 
cause the  additional  expenses  for  dispensary  and  accident 
ward  are  more  or  less  fixed  and  do  not  increase  proportionate- 
ly with  the  increase  in  the  size  of  an  hospital.  Two  dollars 
and  a  half,  therefore,  may  be  considered  a  fair  estimate  of  the 
running  expenses  of  a  hospital,  per  bed  per  day,  for  the  im- 
mediate future.  This  figure  as  a  basis  of  bed  endowment  for 
the  Roosevelt  Hospital  is  subject  to  a  12$  reduction  because 
experience  proves  that  only  80^  of  its  hospital  days-care  are 
free  and  that  the  hospital  is  paid  by  the  patients  about  60$  of 
the  running  expenses  on  20$  of  the  service. 

On  this  estimate  each  bed  will  cost  per  day  $2.20  and  per 
year  $803.  Roosevelt  Hospital  already  possesses  an  income 
by  which  it  supports  239  beds  (of  which  39  are  for  private 
patients)  with  a  deficit  of  about  $25,000.  The  additional  en- 
dowment therefore,  needed  by  Roosevelt  Hospital,  should  it 
become  a  1,000  bed  hospital,  consists  of  two  items: 

I.     To  meet  the  present  deficit  of  $25,000 

per  year  requires  at  5$ $500,000 

II.  To  endow  800  beds  with  an  individual 
income  of  $803  per  annum  requires 
$16,060  per  bed  or  an  income  of  $642, 

400,  which  is  5$  on 12,848,000 

or  a  total   endowment  additional   to 

present  resources  of $13,348,000 

These  figures  show  the  absurdity  of  the  position  of  most 
New  York  hospitals  which  today  still  offer  to  endow  a  bed  in 


23 

perpetuity  for  $5,000,  although  that  bed  requires  for  its  main- 
tenance the  income  of  $16,060. 

3.  The  endowment  of  a  proper  system  for  teaching  and 
scientific  research  requires  an  endowment  which  will  be  best 
understood  if  developed  upon  a  divisional  basis.  The  ques- 
tion of  salaries  for  the  clinical  workers  in  hospital  services 
has  been  brought  forward  during  the  past  year  in  the  discus- 
sion on  hospital  organization  held  before  the  Mayor's  Com- 
mission. It  seems  wise  for  present  purposes  to  assume  that 
the  whole  attending  staff,  both  directors  of  divisions  and 
assistants  who  shall  have  the  privilege  of  private  practice 
shall  continue  as  heretofore  to  serve  the  hospital  without  sal- 
ary, except  insofar  as  the  College  pays  for  their  teaching 
work.  Those  assistants,  however,  who  perform  scientific 
work  both  in  research  and  diagnosis,  and  who  devote  practi- 
cally all  their  time  to  the  work,  should  be  paid  by  the  Hos- 
pital or  the  College,  or  by  both  combined.  Each  of  the 
eighteen  divisions  would  require  a  salaried  and  unsalaried 
staff,  as  follows  : 

A  sample  Medical  Division  would  be  organized  as  follows  : 

SALARY    FROM 
HOSPITAL 

Director  (Professor  in  the  College,    either    of 

medicine  or  clinical  medicine) None 

1st  assistant  and  attending  physician None 

2d  assistant  and  attending  physician  to   Dis- 
pensary (Chief  of  Clinic) None 

3d  assistant  and  pathologist $2,400 

4th  assistant  and  bacteriologist ,    2,400 

Resident  physician 1, 200 

Interne  staff:  house  physician None 

senior         "         None 

junior         "         None 

Clinical  clerks 4th  year  students 

The  educational  budget  for  a  medical  division  would  be 
$6,000,  and  there  are  contemplated  eight  such  divisions.  The 
total  income  for  the  medical  service  should  be  $48,000,  or  the 
income  on  $060,000. 


24 

A  sample  Surgical  Division  would  vary  a  little,  but  only  a 
little,  from  that  of  the  Medical  Division,  as  follows: 

SALARY  FROM 
HOSPITAL 

Director  (Professor  in  College  of    surgery  or 

clinical  surgery None 

ist  assistant  and  attending  surgeon None 

2d  assistant  and  attending  surgeon  to  Dispens- 
ary (Chief  of  Clinic) None 

3d  assistant  and  registrar    $1,000 

4th  assistant  and  pathologist 2,400 

5th  assistant  and  bacteriologist 2,400 

Resident  Surgeon 1,200 

Interne  staff:  house  surgeon None 

senior        "       None 

junior         "       None 

Clinical  clerks 4th  year  students 

The  surgical  division  requires  one  assistant  more  than 
the  medical  and  its  budget  is  higher,  $7,000;  there  are,  how- 
ever, but  four  such  divisions.  The  total  income  for  surgical 
service,  therefore,  is  $28,000  or  the  interest  on  $560,000. 

The  Special  Services  would  be  organized  thus: 
Operative  services — (Gynaecology,  eye,  throat  and  ear  and 
genito-urinary  surgery). 

Non-operative  services  (neurology,  children). 

SALARY  FROM 
HOSPITAL 

Director    (Professor    in    College    in    specialty 

represented) None 

1  st  assistant  and  attending  specialist None 

2d  assistant  and  attending  specialist  to  Dispens- 
ary (Chief  of  Clinic) None 

3d  assistant  and  pathologist  and  bacteriologist. $2, 400 

Resident  specialist 1,000 

Interne  staff:  house  specialist None 

junior         "        None 

Clinical  clerks 4th  year  students 

This  budget  of  $3,400  per  division  must  be  multiplied  by 
six  and  the  resulting  $20,400  is  the  income  on  $408,000. 


25 

The  scientific  work  would  require  an  oversight  by  a  group 
of  highers  officials  than  the  ones  just  mentioned  as  delegated 
to  the  several  divisions.  The  scientific  divisions  should  be 
linked  to  the  similiar  departments  in  the  College  and  College 
laboratories  should  be  used  for  the  greater  and  more  general 
problems  while  the  Hospital  laboratories  should  be  the  place 
for  routine  diagnosis  work  and  for  subjects  of  investigation 
of  lesser  importance. 

SALARY  FROM 
HOSPITAL 

In  Pathology  there  should  be  a  Director  and 
consulting  Pathologist  (the  Professor  of 
Pathology  at  the  College) None 

ist  assistant  and  pathologist $3,000 

who  should  over-rank  the  clinical  ward 
workers  and  have  charge  of  the  hospital 
laboratory. 

The  laboratory  should  have  a  il  Diener  " 720 

And  a  supply  fund 1,200 

The  same  establishment  must  be  provided  for  Bacteriology, 
for  Clinical  Pathology  and  for  Chemistry,  and  the  annual  budget 
of  $4,920  must  be  multiplied  by  four  to  make  $19,680,  which 
is  the  interest  on  $393,600. 

To  summarize  these  items  the  total  sum  needed  amounts 
to  $16,669,600,  divided  as  detailed  above  as  follows: 

For  new  buildings $1,000,000     $1,000,000 

Endowment  for  hospital   expenses   to 

meet  present  deficit 500,000 

To   endow  800  new  beds    at    $16,060 

per  bed 12,848,000     13,348,000 

Endowment  for  teaching  and  medical 
research : 
8    Medical    divisions    at    $120,000 

each 960,000 

4    Surgical    divisions    at    $140,000 

each 560,000 

6  Special  divisions  at $68,000  each.       408,000 

4  Laboratory    services   at   $98,400 

each  393,600 

$2,321,600 

Total $16,669,600 


26 


Of  this  large  sum  $500,000  is  needed  to  meet  the  deficit  in 
the  present  running  expenses;  $1,000,000  for  new  buildings; 
$12,848,000  to  furnish  the  endowment  for  the  additional  work 
in  the  wards  and  $2,321,600  to  supply  the  funds  for  teaching 
and  medical  research  both  in  the  present  hospital  and  in  the 
additions  to  be  built. 

It  is  desirable  to  consider  these  propositions  from  the 
standpoint  of  the  separate  services  in  order  that  a  correct 
idea  may  be  had  of  what  portions  of  the  total  amount  may  be 
necessary  for  urgent  use,  what  parts  may  be  desirable  but 
not  immediately  needed  for  present  development,  and  what 
proportion  of  the  whole  may  conveniently  and  properly  be 
left  to  the  future  extension  of  the  hospital  plant.  Such  a 
presentation  also  will  serve  as  a  useful  index  to  direct  the 
proposed  gifts  of  any  prospective  donor  of  funds  to  the 
hospital.  On  studying  the  various  items  from  this  point  of 
view  the  following  facts  may  be  stated: 

Each  completed  clinical  division  would  require  the  follow- 
ing endowment,  apart  from  the  necessary  buildings: 

A  Medical  Service  of  50  beds  would  require  an  endowment 
as  follows: 

For  Hospital  bed  endowment $803,000 

For  teaching  and  research 120,000 

$923,000 

To  endow  a  Surgical  Service  of   100  beds  would  require  the 
following  amount  of  money: 

For  Hospital  bed  endowment.  . .  .$1,606,000 
For  teaching  and  research 140,000 

$1,746,000 

For  a  Special  Service  of  50  beds  (e.g.,  Eye,  Children)  the  fol- 
lowing sums  are  needed: 

For  Hospital  bed  endowment $803,000 

For  teaching  and  research 68,000 

$871,000 


27 

For  a  Special  Service  of  25  beds  (e.g.,  Throat  and  ear,  Genito- 
urinary, Gynaecology,  Neurology)  the  needed  endowment 
amounts  to: 

For  Hospital  bed  endowment $401,000 

For  teaching  and  research 68,000 

$469,000 

The  present  demands  upon  the  service  at  Roosevelt  Hos- 
pital require  an  enlargement  of  the  plant  to  about  double  its 
present  size.  To  fulfil  these  present  needs  for  charitable  ends, 
for  teaching  and  for  research,  the  following  five  items  of  the 
total  foundation  of  $16,000,000  proposed  above  are  urgently 
needed: 

I.  The  four  laboratory  services  at  $98,400 
each  would  require  a  total  endowment 
of  $393,6oo 

II.     The    endowment    to    meet    the    present 

deficit  is 500,000 

III.  The  erection  of  at  least  one  of  the  pro- 
posed new  ''barrack"  pavilions,  prefer- 
ably the  one  to  replace  the  "ward  5  " 
building,  requires 250,000 

IV.  The  endowment  of  255  additional  beds  at 
$16,060  each  to  meet  the  present  de- 
mands for  hospital  facilities,  amounts 
to 4,095,300 

.  V.     The  endowment  of  the  teaching  and  re- 
search   staffs   for   the    eight  divisions 
created  by  the  above  additions  is,  in 
detail,  as  follows: 
4  medical  divisions  at  $1 20,000 

each,  or $480,000 

2  surgical  divisions  at  $140,000 

each,  or 280,000 

2  special  divisions  (Children, 

Gynaecology),    at    $68,000 

each,   or 136,000 

and  would  make  a  total  sum  of $806,000 


28 

These  five  items,  forming  the  urgent  needs  of  Roosevelt 
Hospital  to-day,  present  a  total  sum  of  $6,134,900,  to  be 
secured  in  order  to  carry  out  the  plans  for  modernizing  the 
methods  of  teaching'  and  research  now  in  vogue,  and  for 
meeting  the  demands  for  charity  now  being  made  on  the 
hospital. 

The  present  hospital  facilities  provide  approximately  250 
(actually  238)  beds,  divided  into  two  surgical  divisions  of 
44  beds  each.  One  medical  division  of  70  beds,  one  gynaeco- 
logical division  of  29  beds,  one  children's  division  of  12  beds 
(part  of  the  medical  service)  and  private  patients  beds  amount- 
ing to  39. 

These  five  divisions  should  be  standardized  as  to  beds  on 
the  basis  detailed  above,  with  the  possible  exception  of  the 
children's  service.  But  it  would  seem  wise  to  have  the  num- 
ber on  this  children's  service  (12)  increased  to  25,  and  it 
should  be  separated  from  the  general  medical  service. 

The  additional  endowment  of  255  beds  would  complete  the 
surgical  divisions  to  an  100  bed  standard,  the  medical  service 
to  4  divisions  of  50  beds  each;  the  gynaecological  service 
would  be  left  intact  and  the  children's  service  would  be  made 
a  special  service  of  25  beds,  which  would  be  half  that  pro- 
posed for  the  final  establishment. 

In  an  original  appeal  on  this  subject  which  was  formulated 
on  May  19,  1905,  it  was  suggested  that  one  million  dollars 
would  secure  the  advantages  for  teaching  which  in  the  present 
statement  is  placed  at  six  times  as  much.  The  original  plan 
was  to  enable  the  College  and  the  Hospital  to  use  the  present 
hospital  plant  for  medical  teaching  upon  the  best  modern 
methods.  The  study  of  the  whole  situation  has  developed  the 
facts  that  the  present  hospital  plant  is  about  half  the  size  it 
must  be  to  meet  its  philanthropic  task  ;  and  further,  that 
medical  research  cannot  be  divorced  either  from  the  general 
hospital  or  from  the  teaching  institution.  The  demand  for 
six  millions  instead  of  for  one  million  dollars  is  made  neces- 
sary, therefore,  by  the  urgent  present  requirements  for  an 
hospital  of  twice  the  size  of  the  present  Roosevelt  for  teach- 
ing facilities  and  for  a  teaching  staff  in  the  enlarged  institution 
and  for  a  thoroughly  equipped  research  plant  in  connection 
with  both.      In  other  words,  medical  education  at  the  College 


29 

of  Physicians  and  Surgeons  and  at  the  Roosevelt  Hospital  de- 
mands both  the  million  dollar  fund  needed  to  develop  the 
present  Roosevelt  and  the  five  million  dollar  "University 
Hospital  "  to  be  added  to  the  present  Roosevelt,  both  of  which 
were  specifically  mentioned  in  the  appeal  of  May  19,  1905, 
already  referred  to. 

The  addition  at  the  present  time  of  special  services  other 
than  those  of  children  and  gynaecology  is  a  less  urgent  neces- 
sity than  the  endowment  of  the  general  surgical  and  medical 
services  to  a  complete  total  of  200  surgical  beds,  200  medical 
beds  and  the  addition  of  the  much  needed  laboratory  services. 
The  endowment  for  these  additional  special  services  would  be, 
as  already  stated,  $871,000  for  a  service  on  the  eye,  and  $469, 
500  for  each  of  the  others  suggested.  At  the  present  time 
there  is  no  question  but  that  these  special  services  are  more 
important  from  a  College  point  of  view  than  from  a  Hospital 
point  of  view.  They  could  undoubtedly  be  filled  with  patients 
but  unless  the  funds  are  provided  by  special  endowment  they 
should  not  be  considered  at  the  present  time.  Whenever 
these  specialties  are  added  to  the  hospital  foundation,  a  fur- 
ther demand  must  be  made  upon  the  proposed  building  funds, 
probably  to  involve  the  equipment  of  one  of  the  $250,000 
"  barrack  "  pavilions.  The  remainder  of  the  total  expenditures 
of  $16,669,600  will  be  needed  ultimately  for  the  develop- 
ment of  the  service,  the  establishment  of  an  additional  200 
surgical  beds  and  200  medical  beds,  with  the  appropriate 
buildings. 

This  detailed  statement  of  expenditure  needed  for  the  de- 
velopment of  Roosevelt  Hospital  if  adopted  by  the  hospital 
will  give,  it  is  hoped,  an  index  for  prospective  donors  of  funds 
desiring  to  advance  medical  education  and  research  whereby 
they  may  select  the  particular  line  of  work  which  they  may 
wish  to  foster  with  the  knowledge  that  the  work  will  be  carried 
on  in  an  institution  where  the  best  possible  results  may  be  as- 
sured, and  in  that  their  benefactions  may  be  for  all  time  avail- 
able for  the  sick  poor  in  New  York  City,  for  medical  education 
in  the  whole  country  and  for  medical  research  in  the  civilized 
world. 

It  is  earnestly  hoped  that  this  presentation  of  the  relation 
of  medical   education  and   research   to   hospital   organization 


3° 

may  assist  your  Committees  in  their  work,  and  it  is  hereby 
respectfully  submitted. 

Samuel  W.  Lambert, 

Dean. 


College  of  Physicians  and  Surgeons, 

Medical  Department  of  Columbia  University, 

Wednesday,  November  25th,  1908 


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